Swimming Lessons Registration Form Student InformationHow many students do you want to register?* One Two Three Four Five Student #1Type of lesson requested*Public Group ($8 per lesson)Private ($25 per lesson)Semi-Private ($15 per student)Homeschool Program ($9 per lesson)Student #1 Name* First Last Date of Birth* MM slash DD slash YYYY Skill Level*1 – Beginner2 – Comfortable3 – Basic Strokes4 – Strokes 25 Yards5 – Stroke Refinement6 – AdvancedParent / ChildPreschool (3-5yrs)Day/time Requested*Private Lessons M – 5-7pmPrivate Lessons T 5-6pmPrivate Lessons W 5-7pmPrivate Lessons Thurs 5-6pmPrivate Lessons F 5-7pmPrivate Lessons Sat 9:35-12pmTuesday / Thursday Group Lessons- 5-7pmSaturday Group Lessons- 9:30-12pmEmergency Contact Person* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Student #2Type of lesson requested*Public Group ($8 per lesson)Private ($25 per lesson)Semi-Private ($15 per student)Student #2 Name* First Last Date of Birth* MM slash DD slash YYYY Skill Level*1 – Beginner2 – Comfortable3 – Basic Strokes4 – Strokes 25 Yards5 – Stroke Refinement6 – AdvancedParent / ChildPreschool (3-5yrs)Day/time Requested*Monday Privates – 5-7pmTuesday Privates 5-6pmWednesday Privates 5-7pmThursday Privates 5-6pmFriday Privates 5-7pmSaturday Privates 9:35-12pmTuesday / Thursday Group Lessons – 5-7pmSaturday Group Lessons – 935-12pmDoes this student have the same emergency contact info as above?* Yes No Emergency Contact Person* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Student #3Type of lesson requested*Public Group ($8 per lesson)Private ($25 per lesson)Semi-Private ($15 per student)Student #3 Name First Last Date of Birth* MM slash DD slash YYYY Skill Level*1 – Beginner2 – Comfortable3 – Basic Strokes4 – Strokes 25 Yards5 – Stroke Refinement6 – AdvancedParent / ChildPreschool (3-5yrs)Day/time Requested*Monday Privates – 5-7pmTuesday Privates 5-6pmWednesday Privates 5-7pmThursday Privates 5-6pmFriday Privates 5-7pmSaturday Privates 9:35-12pmTuesday / Thursday Group – 5-7pmSaturday Group – 935-12pmDoes this student have the same emergency contact info as above?* Yes No Emergency Contact Person* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student #4 Name First Last Date of Birth* MM slash DD slash YYYY Skill Level*1 – Beginner2 – Comfortable3 – Basic Strokes4 – Strokes 25 Yards5 – Stroke Refinement6 – AdvancedParent / ChildPreschool (3-5yrs)Day/time Requested*Monday Privates – 5-7pmTuesday Privates 5-6pmWednesday Privates 5-7pmThursday Privates 5-6pmFriday Privates 5-7pmSaturday Privates 9:35-12pmTuesday / Thursday Group – 5-7pmSaturday Group – 935-12pmDoes this student have the same emergency contact info as above?* Yes No Emergency Contact Person* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Δ
